Teaching and Evaluation of Suicidal Assessment, Five-Step

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Teaching and Evaluation of Suicidal Assessment, Five-Step Teaching and Evaluation of Suicidal Assessment, Five-Step

Evaluation and Triage (SAFE-T) in the Emergency Department Evaluation and Triage (SAFE-T) in the Emergency Department

Evangeline Rico California State University, Northern California Consortium Doctor of Nursing Practice

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Teaching and Evaluation of Suicidal Assessment, Five-Step Evaluation and

Triage (SAFE-T) in the Emergency Department

Evangeline Rico, RN, MSN, WCC, CNL

California State University, Northern California Consortium

Doctor of Nursing Practice

A project

submitted in partial

fulfillment of the requirements for the degree of


California State University, Northern Consortium


May 2016

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ABSTRACT

Teaching and Evaluation of Suicidal Assessment, Five-Step Evaluation and

Triage (SAFE-T) in the Emergency Department

Suicide remains to be a global and a national problem, and it continues to

be one of the leading causes of death in the United States (U.S.) The Emergency

Department (ED), being the gateway to the hospital can provide a great

opportunity to assess each patient for suicidal ideation, and evaluate if patients

present with risk factors for suicide. The competency of the ED staff plays a

critical role in early recognition of patients who are at risk, and in implementing a

plan of care for those with positive screens. However, researchers showed that

knowledge deficit and lack of education regarding suicide assessment have

contributed to failure in identifying high-risks suicidal patients. Failure to identify,

monitor and provide early interventions can result in adverse sentinel events.

This study examined the effect of teaching the ED nurses the Suicidal

Assessment, Five-Step Evaluation and Triage (SAFE-T), an evidenced based tool

for suicide assessment designed for ED triage. This study measured post-teaching

intervention to assess if SAFE-T teaching increased knowledge of nurses

regarding assessment and care of suicidal patients. The results showed that SAFE-

T teaching increased nurse’s knowledge in identifying risk and protective factors,

it showed improved suicide inquiry, and increased knowledge in nursing

determination of risk level and appropriate nursing intervention.

Evangeline Rico May 2016

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DEDICATION

I would like to dedicate this project to the memory of my mother, Clarina S.

Apolinario. Thank you for your love, for believing in me despite everything, and

for instilling in me the value of education. Achieving a doctorate degree has been

a lifelong dream, and this is one for you my dear Nanay Claring! And to Mama

Cely, this one’s for you too! I grew up reading your books in the library. You’re

my inspiration and my hero! Thank you for all your love and support! You gave

up so much for all of us, we will be forever grateful.

“All that I am, or hope to be, I owe to my mother.” ~Abraham Lincoln.

ACKNOWLEDGMENTS

I would like to acknowledge various people who have taken the journey with me

in the recent years as I worked on this dissertation. My deepest gratitude to my

husband Chris Rico, who is my other half, my love and my rock. Thank you for

the never ending support and allowing me to pursue my dreams! To my sons

Christian Mikhail and Chancel Markus, thank you for your care, generosity,

support and unconditional love throughout the years. You both bring so much joy

and sunshine in my life!

To the Apolinario and Rico family, thank you for your love and understanding.

You have cheered for me and provided encouragement when it was difficult to

find balance with life, school and work. You never stopped believing in me and

you have no idea how much your guidance and reassurance gets me through the

toughest times. I am so fortunate to have you all in my life!

Also, my heartfelt gratitude to our Crossroads Christian Center family. I am very

grateful for all the prayers and fellowship! Every Sunday at church, as I type away

my paper, I thank you all for being with me through all the ups and downs!

Special thank you to Dr. Christine Ortiz, who helped and provided guidance from

the beginning until the end. And to Dr. Debra Hummel who has been a great

classmate, mentor, and friend throughout the doctorate program- you are a gem!

Most importantly, thank you Lord Jesus Christ for all the wonderful blessings that

are too many to count. Thank you Lord for everything! To God be the glory!

“For nothing will be impossible with God.” ~ Luke 1:37

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TABLE OF CONTENTS

Page

CHAPTER 1: INTRODUCTION ............................................................................ 8

Background of the Problem .............................................................................. 9

Statement of the Problem ................................................................................ 10

Purpose of the Study ....................................................................................... 10

Benefit of the Study ........................................................................................ 12

Research Question ........................................................................................... 12

Theoretical Framework ................................................................................... 13

Definition of Terms ......................................................................................... 16

CHAPTER 2: LITERATURE REVIEW ............................................................... 17

Risk Factors for Suicide .................................................................................. 18

Epidemiological Findings……………………………………………………22

Suicide Assessment and Management……………………………………….23

Results and Gaps in Research ......................................................................... 26

Summary ......................................................................................................... 29

CHAPTER 3: METHODOLOGY .......................................................................... 30

Research Design and Method ......................................................................... 30

Potential Benefits ............................................................................................ 31

Subject ............................................................................................................. 32

Consent ............................................................................................................ 33

Setting…. ........................................................................................................ 33

Potential Risks and Management of Risks ...................................................... 33

Costs… ............................................................................................................ 35

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Compensation and Incentive……..………………………………………….35

Post-Teaching Evaluation Tool ....................................................................... 35

Analyzing Data ................................................................................................ 35

Gaps in Literature ............................................................................................ 36

Study Step Sequence ....................................................................................... 35

CHAPTER 4: RESULTS ....................................................................................... 37

Introduction ..................................................................................................... 37

Sample Demographics .................................................................................... 38

Reliability Analysis ......................................................................................... 40

Descriptive Statistics and Data Screening ...................................................... 42

Research Question ........................................................................................... 43

Ancillary Analysis ........................................................................................... 46

CHAPTER 5: CONCLUSION ............................................................................... 48

Discussion ....................................................................................................... 48

Limitations ...................................................................................................... 49

Implication of Nursing Practice ...................................................................... 50

Conclusion ....................................................................................................... 51

REFERENCES ....................................................................................................... 53

APPENDIX A: CONSENT FORM ....................................................................... 62

APPENDIX B: POST-TEACHING EVALUATION FORM ............................... 64

APPENDIX C: TEACHING MATERIALS .......................................................... 68

APPENDIX D: SAFE-T HANDOUT .................................................................... 78

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CHAPTER 1: INTRODUCTION

Suicide remains to be a global issue, and approximately 1 million die

annually all over the world (World Health Organization, 2011). According to the

Centers for Disease Control and Prevention (CDC) (2007), suicide was the 11th

leading cause for all Americans, and it is also the 3rd leading cause of death

between 15-24 years of age (CDC, 2007). The Joint Commission (JC) (2010)

stated that suicide is one of the most reported sentinel event, and 8% of suicide

attempts occur in the Emergency Department (ED) (JC, 2010).

The Department of Veterans Affairs (VA) examined suicide in the military

veterans and showed that an average of 18 veterans committed suicide on a daily

basis (Huggins, 2011). Veterans presenting with higher suicide rate is associated

with availability and knowledge in use of firearms, psychiatric conditions such as

depression, post-traumatic stress disorder (PTSD) (Dausey, Desai, & Rosenbeck,

2005), and traumatic brain injury (Warden, 2006). Among all of these, PTSD is

the most common mental disorder resulting from military combat and is caused by

trauma, life threatening events, natural disaster, terrorist attack, accidents or

personal assaults (Nayback, 2008).

Background

When a patient checks into the ED, the triage nurse makes the first contact

with the patient. The triage is defined as the prioritization of care based on the

symptom, disease, acuity, diagnosis and the availability of resource (Seefeld,

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2008). It is very important that the triage nurse quickly identifies the patient who

requires urgent medical attention and start interventions as appropriate to those

who needs it the most (Trzeciak & Rivers, 2003). Efficient and effective triage is

important because if assessments are done too long in the triage area, it can lead to

delay in care of the incoming patients awaiting to be seen in the ED. Prolonged

wait times can lead to delays in time-sensitive treatments, which can leave patients

without medical assistance and can result in adverse events or contribute to poor

health outcomes (Moll, 2010).

Triage is one of the most critical component of the ED, therefore it is

imperative that the triage nurse is competent to perform an efficient and

comprehensive assessment for suicidal ideation (SI), and suicide risk assessment.

The triage nurse must be able to communicate effectively, and consistently assign

a triage category that reflects the patient’s clinical needs (Doyle et al., 2012;

Howard et al., 2012; Marino et al., 2014). The JC (2010) also states that each

patient must be screened for any suicidality (JC, 2010) and to assess for mental

health, suicidal intent, psychosocial history and suicidal thoughts and ideations

(Sun, Long, Boore, & Tsao, 2006).

This DNP project would be very beneficial to the VA institution by

providing the ED nurses education regarding the Suicide Assessment Five-Step

Evaluation and Triage (SAFE-T) tool. The SAFE-T provides an evidence-based

structure for conducting a comprehensive suicide risk assessment, which includes

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identification of risk and protective factors, thorough suicide inquiry,

implementation of interventions that matches the risk level, and appropriate

nursing documentation (Jacobs, 2007).

Statement of the Problem

This VA ED triages approximately sixty to eighty patients per day. The

patient population includes different medical conditions, as well as mental health

patients with depression, mood disorder, substance abuse, psychiatric problems,

post-traumatic stress syndrome, or other mental health issues that may present with

suicidal ideation. Currently, per hospital policy, all patients seen in the ED are

triaged by the nurse, and are assessed for SI. However, it is problematic to assess

patients for SI consistently due to lack of standardized education regarding

screening and care of suicidal patients. As a result, the assessment and care of

patients with SI is inconsistent amongst the nurses. This can potentially result in

adverse event such as suicide attempt in the ED, or potential for missing high-risk

SI patients during the triage assessment.

Purpose

Patients that are having SI may seek help and medical assistance in the ED.

It is critical for the staff to evaluate the lethality of the situation and help in

providing a safe environment of care (Mitchell, Garand, Diane, Panzak & Taylor,

2005). The CDC (2007) reported that there are approximately 100 to 200 attempts

for every completed suicide. Suicide does not happen without any warning signs

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(Tucker, Crowley, Davidson, & Gutierrez, 2015) and suicidal patients seek

medical attention months before the suicide attempt happens (Tran et al., 2014).

Therefore, it is imperative that the ED clinicians correctly identify patients who

are at risk, and be able to implement safety plans to stop the suicide before it

happens.

The goal of this DNP project is to provide teaching for thirty nurses at a

VA ED, regarding the assessment, care, and management of suicidal patients.

According to Perry et al. (2012), the risk factors associated with suicide are

extensive and they have been studied by many researchers. The incidence of

suicide-related events in healthcare facilities have been associated with staff

related factors such as incomplete assessment and inadequate communication (JC,

2013). There are several issues identified in literature including lack of

environmental assessment and inadequate staff training (Patterson & Hughes,

2008), necessity for staff training and education (Reid, 2010) and education

regarding the identification of risk factors (Combs & Romm, 2007), and the

reduction of environmental risk factors (Watts et al., 2012).

This DNP project included teaching 30 ED registered nurses regarding the

SAFE-T tool. The SAFE-T incorporates the American Psychiatric Association

Practice Guidelines for the Assessment and Treatment of Patients with Suicidal

Behaviors (APAPGATPSB), as well as the recommendations from JC Patient

Safety Goals on Suicide. The SAFE-T suicide assessment tool is also supported by

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Screening for Mental Health Inc. and the Suicide Prevention Resource Center

(Jacobs, 2007). The SAFE-T teaching included information regarding suicide

assessment, recognizing risk factors, identification of protective factors,

conducting suicide inquiry, and will provide guidance regarding nursing care and

interventions based on the patient’s suicide risks (Jacobs, 2007).

Benefits

The benefits of providing ED nurses with teaching regarding assessment,

care and management of suicidal patient include satisfying the JC National Patient

Safety Goal (NPSG) #15, which mandates that the organization identify safety

risks present in its patient population. This include the: 1.) Assessment of

variables that may increase or decrease risk of suicide, 2.) Meeting the patient’s

safety needs, and setting for treatments are addressed, 3.) The organization

provides information to individuals and their family members for crisis situations

(JC, 2013). More importantly, educating the nurses will increase safety in the ED

because it will provide consistency, guidance and structure for the nurses

managing this high-risk patient population.

Research Questions

The project was derived from a need to improve the nursing education regarding

triage assessment of suicidal patients in the ED.

1. Would the use of SAFE-T teaching increase the knowledge regarding assessment and

care of suicidal patients in the ED?

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2. Would the use of SAFE-T teaching increased knowledge regarding conducting

suicide inquiry and identifying risk factors?

Theoretical Framework

Hildegard Peplau’s Theory of Impersonal Relations (TIR) was selected as

the conceptual framework for this DNP project. Peplau’s TIR is a middle-range

theory developed in 1952. She stated that nursing is an interpersonal process that

involves the interaction between the nurse and the patient (Peplau, 1952). Peplau

stated that the nurse-patient relationship is the most basic human connection that is

essential in providing nursing care. The accomplishment of a common goal can be

done through the different phases between the nurse-patient relationship, and that

these phases has a beginning, goes through particular stages, time-limited, and has

an end (Peplau, 1952). The four sequential phases include 1.) Pre-orientation, 2.)

Orientation, 3.) Working, and 4.) Resolution phase. In addition to the different

phases, Peplau also believed that the nurse has six nursing roles in the nurse-

patient relationship, which include stranger, resource person, educator, leader,

surrogate and therapist (1952).

The Pre-Orientation Phase happens during the triage assessment when the

first contact and communication happens between the nurse and the patient. The

reason for triage in the ED is to prioritize the incoming patients and to identify

those who need immediate medical attention, and those who can wait to be seen

by the physicians based on the presenting symptoms. The triage is important

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because this will determine whether the patient can safely wait for interventions,

or require immediate medical care (Gilboy, Tanabe, Travers & Rosenau, 2012).

The second is Orientation Phase (Peplau, 1952), and this when the ED

nurse and the patient gets familiar in the triage area, and starts to form trust and a

connection with each other. There are many variables between the nurse-patient

relationship that can affect the orientation such as belief, culture, expectations,

past experiences, personal expectations, race, and values. The initial role of the

nurse during the orientation phase is the “stranger,” and the initial bonding

between the nurse and the patient during this phase is vital in establishing trust

with one another. This is the phase where the patient problem is identified, and the

nurse can decide on the course of action or plan of care for the patient (Butts &

Rich, 2011). This is the phase where the relationship grows as the patient asks

questions, shares more information and verbalizes their expectations. The nurse

reacts, responds, explains the plan, and helps to identify issues and patient

concerns. There is a time limit for this interaction, therefore it is imperative that

the outcome for the patient is established within a short amount of time, and a plan

of care is communicated (Butts & Rich, 2011).

The third is the Working Phase (Peplau, 1952), and this occurs in the ED

room where therapeutic interventions are initiated by the ED nurse. The nurse

portrays many different roles in this phase when the patient’s specific medical

problems are attended to. For example, diagnostic tests are conducted, healing

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treatments are started, and nursing care is provided. The working phase is when

the nurse is actualizing the role of the caregiver and at the same time the educator,

patient advocate, leader and a resource (Butts & Rich, 2011). The ED nurses’ goal

is to meet the needs of the patient, and to be able to communicate therapeutically

in order to explore all avenues to help the patient progress towards healing.

The last is the Resolution Phase (Peplau, 1952), is when the crisis is over

and the patient is stabilized in the ED rooms. This is basically the conclusion of

the professional connection, and this is when the ED nurse-patient relationship

ends (Butts & Rich, 2011), and sometimes it can be difficult for the nurse and the

patient because they create a strong bond. However, the patient needs have been

met at this point, and this is the time for the patient to sever the connection with

the nurse. In the end, both the patient and the nurse achieve a sense of balance and

develop their emotional maturity (Butts & Rich, 2011). The ED nurse portrays

different nursing roles in this phase including teacher, resource, counselor,

advocate and leader (Butts & Rich, 2011).

All of the phases described by Peplau happens within the nurse-patient

interaction in the ED. Understanding all different phases is critical so that the

nurse can identify the different roles that they assume as they transition to the next

phase. Having an awareness of the interpersonal process can help the nurses create

meaningful and therapeutic interactions with the patient as they both go through

the pre-orientation, orientation, working and resolution phase.

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Definition of Terms

The following definitions are used for the purpose of this study:

Acuity. The severity of the patient’s illness. The higher the acuity of the

patient means the higher the severity of the illness. The implication is

immediate medical care needs to be provided, otherwise it can result in loss

of limb or life (Emergency Nurses Association, 2010).

Nursing Care Plan. This outline and summarizes the care to be given

according to the nursing diagnoses and the nursing assessment (Mosby,

2009).

Sentinel Event is defined by JC as unforeseen adverse event such as

fatality, or severe health risk not associated with the patient’s disease

process (JC, 2013).

Suicide Attempt. To inflict pain or harm to one’s self without any intent to

die (Jacobs, 2007).

Suicidal Ideation. Thoughts of harming self and causing one’s death

(Jacobs, 2007).

Suicidal Intent. Yearning to cause do self-destructive or deadly act to one’s

self (Jacobs, 2007).

Triage. Triage is the process used in the ED where the nurse conducts a

brief problem focused assessment, and then determine the patient acuity

level whether they need to be seen immediately, or the patient can safely

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wait for their medical care and treatment (Gilboy, Tanabe, Travers, &

Rosenau, 2012).

CHAPTER 2: LITERATURE REVIEW

The review of literature provided a framework for examining the concepts of the

DNP project. The following databases were utilized: CINAHL and Pub Med. The search

used the following keywords and phrases: emergency department, emergency room,

suicide, suicide in the ED, suicide in the ER, suicide veterans, suicide assessment tool,

suicide assessment in the ER, suicide assessment in the ER, triage assessment, triage

assessment for suicide, suicide care plan, suicide care plan in the ED, suicide. The

original searches generated approximately 463,000 results. The sources identified

included abstracts, journals, articles, book reviews, and web resources. The search was

limited to scholarly publications from 2000 to 2015. The majority of the articles were

from 2007 to 2015. The original search showed publications in a broad range of subject

area including medicine, publication health, psychology, language and literature, biology,

nursing and practice. The search was limited to adult population, veterans, suicide

management, suicide risk assessment, emergency department, suicide assessment, and

nursing.

Jayaram (2014) stated that there is no single measurement or technique that

can precisely foresee suicide risks. There are also differences in language and

clinical practice, and there is much need for education and standardization

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(Jayaran, 2014). This is also supported by other studies that show insufficient

evidence regarding universal suicide screening, the lack of data identifying a

validated screening tool, and due to the complexity of therapies to reduce suicide

attempts (Allen et al., 2013; U.S. Preventive Services Task Force [USPSTF],

2014).

One resonating theme throughout the literature review was that healthcare

providers should conduct a comprehensive assessment that include mental and

psychiatric health questions, history, diagnosis, suicide risk factors, plan, intent,

protective and modifiable risk factors, as well the need for further education for all

ED clinicians in regards to these topics (Betz et al., 2013; Chesin & Stanley, 2013;

Combs & Romm, 2007; Jayaram, 2014; Tran et al., 2014; Reid, 2010).

Risk Factors for Suicide

The researcher suggested clinicians need to know the following risk factors

when assessing patients for suicide. There are many health issues identified for the

suicidal veteran population, and these include attitude toward death and grieving,

ethics, gender, healthcare disparities, and psychiatric conditions. Literature review

revealed that all of these variables showed increased risk for behavioral illness,

disability and suicide (Nayback, 2008).

Health Disparities. Nayback (2008) identified poverty as one of the most

influential factors that impact healthcare. The VA Healthcare System attempts to

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address the issue of poverty, and to increase access of veterans to medical care.

The common barriers include the lack of healthcare insurance, inconsistency in

medical coverage, and receiving poor quality of care for black or hispanic

(Nayback, 2008). To address these concerns, the VA developed programs that

would increase access to healthcare even in remote areas such as telephone-link

care, primacy care in outpatient clinics, online referrals or financial assistance, or

employment program that would grant priority hiring to veterans. The focus

includes the Operation Enduring Freedom and Operation Iraqi Freedom, as these

populations are known to have increased rate of PTSD (Tanielian & Jaycox,

2006), and attempts are made to help them as they return back from their military

tours.

Psychiatric Conditions. There are more than 1.6 million men and women

who have served in the military during the Operation Iraqi Freedom (OEF) and

Operation Enduing Freedom (OEF) since 2001 (Tenelian & Jaycox, 2008). These

veterans were exposed to many stressors, austere environment, different

surroundings and strenuous physical demands in a foreign country, traumatic

events such as witnessing deaths, gunshot wounds, explosive bombs, and the

constant fear of dying. The problem is that the suicide rates among the veterans

are higher in comparison to the general U.S. population (McCarthy et al., 2009).

Brenner et al. (2011) showed that a history of PTSD was associated with increased

risk for a suicide attempt in veterans receiving mental health services, compared to

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those without PTSD (Brenner et al., 2011; Jakupcak et al., 2009). It was also noted

that irrespective of race, 90% of suicide-related deaths have a psychiatric

condition at the time of their death that is diagnosed or not treated (Ting, Sullivan,

Boudreaux, Miller, & Camargo, 2012).

Gender Issues. Ronquillo, Minassian, Vilke, & Wilson (2012) evaluated

the different approaches and ways suicide are executed between genders. Results

showed that women have higher rates of attempts, and the men have higher rates

of completing lethal suicides. The most common suicide methods for women

included drug overdose and exsanguination, while males used more lethal ways

such as hanging and asphyxia. Ronquillo et al. (2012) revealed that women are the

“attempters” and “survivors” of suicide attempts, while men are “completers” and

employ more lethal means in their suicidal attempt. The most common method of

suicide used include use of gun as weapons, hanging, medication or drug

overdose, poisoning, jumping, asphyxiation, vehicular impact, drowning,

exsanguination and electrocution (Tal Young et al., 2012). Differences between

gender issues are important to know because the number of women veteran being

seen in the ED is steadily increasing. They are considered high-risk because most

of them are being treated for PTSD, mental health issues, traumatic brain injury, or

military sexual trauma (Nayback, 2008).

Attitudes toward Death, Loss and Grieving. There are many different

kinds of grief, and they are categorized based on the grief response and features.

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The effects of suicide or profound loss on the loved ones left behind can be

devastating and life changing (Tal Young et al., 2012). This is mostly the case

with veterans who are left behind and witnessed their colleague die in the military

tour of duty. When the military personnel is deployed to combat zones, they are

subjected to harsh environment, under extreme amount of stress, and surviving in

conditions where there is a constant threat to their lives. Unfortunately, not all of

them survive and when they witness a death of a colleague, it creates a sense of

loss that is hard to overcome. It is normal to have prolonged sadness, and go

through bereavement process after a loved one dies, however, Tal Young et al.

(2012) found that suicide survivors are confronted with different challenges

compared to other mourning the loss of their loved ones from other types of death

(Tal Young et al., 2012).

According to Tal Young et al. (2012), suicide survivors are unique, and

face many variables that can affect the normal grieving process. There are certain

factors that make grieving longer and more painful such as feelings of

overpowering guilt, incomprehension, denial, embarrassment, anger, and feeling

of stigma (Tal Young et al., 2012). Researchers also showed that those who

experienced loss of a love one from suicide have a higher risk for suicidal ideation

compared to other bereaved population (Krysinka, 2003; Runeson & Asberg,

2003). As a result, survivors should be evaluated for post-traumatic stress

syndrome, depression and suicidal ideation (Tal Young et al., 2013). Therefore, it

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is imperative to ask the patient or the family if they have strong family support. If

available, therapy or support group should be offered, and they should be educated

about positive coping skills so that they can go through the normal grieving

process.

Epidemiological Findings. Many evidence-based risk factors identified above are

missing in this VA ED suicide assessment and management. These include assessment of

awareness of gender issues, patient inquiry regarding access to drugs or weapons, prior

history of suicide (Gold, Applebaum, & Stanley, 2011), chronic illness, hopelessness and

mental health disease such as PTSD, depression and existing mental health problems

(Giordano & Stichler, 2009). Joint Commission (2013) reported that suicide remains to

be a sentinel event in many acute and inpatient hospital settings, which requires an

immediate investigation and response (JC, 2013). According to JC (2013), suicide

remains to be one of the top five causes of sentinel events, ranking higher than

medication errors, and is the 10th leading cause of death for persons 10 years of age and

older (JC, 2013).

Jayaram (2014) acknowledged that the increased rates of suicide in healthcare

facilities are due to environmental and staffing-related issues, which include lack of

training and inadequate assessment, lack of communication, and poor information

management (Jayaram, 2014). From December 1999 to June 2006, there were 52%

suicides-related root cause analyses at VA hospitals. Suicide is a more prevalent cause of

death in comparison to motor vehicular accident, and the rate has been increasing in

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prevalence over the past two decades (Tran et al., 2014).

The evidence suggested that risk factors for suicide include health disparities,

psychiatric conditions, gender issues, attitude towards death, episode of profound grief,

or loss of love ones should be included in the triage assessment. The SAFE-T teaching

plan included the comprehensive assessment of all of these risk factors that were

identified in the studies (Jacobs, 2007).

Suicide Assessment and Management

Due to increasing sentinel events involving suicide, the JC NPSG (2013)

required healthcare organizations to assess patient’s risk for suicidality, and to put

more focus especially on patients with primary mental health conditions (JC,

2013). In order to study if the JC mandates made a difference, Robst (2015)

conducted a quantitative study that looked at the effectiveness of JC Safety Goals

in reducing suicide attempts in ED using pre and post JC implementation data

comparison to check for reduction of suicide attempts. Robst showed that suicide

rates declined for mental health patients (2015). However, it did not show

significant changes to those patients with primary medical health diagnosis. Robst

raised questions whether the JC Safety Goals should be extended to include all

patients coming in with all conditions, versus limiting suicidal assessment efforts

to mental health patients only (2015).

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In order to examine if targeted staff education will help in improving ED

assessments and treatment of suicidal patients, Betz et al. (2013) evaluated the

knowledge, attitudes, and practices of ED providers in the care of suicidal patients.

Betz et al. (2013) explored the healthcare provider’s approach, awareness, beliefs,

and practices regarding screening and care for suicidal patients. He reported that

the ED providers are confident with suicide screening skills, but there seems to be

a lot of educational gaps particularly a comprehensive mental health assessment,

counseling or referral for those that screen positive for suicide. Betz et al. also

identified educational deficits with risk assessment and implementation and plan

of care for this high-risk population (2013).

To examine the incidents and the number of patients presenting in the ED

with suicide attempts or self-inflicted injury, Ting, Sullivan, Boudreaux, Miller &

Carmargo (2012) conducted a quantitative, longitudinal study in the U.S.

from1993-2008. The data was acquired from the National Hospital Ambulatory

Medical Care Survey (NHAMCS) using sample populations that were selected

over 4-week period from different ED locations. The reason and timing of the ED

visit, timing method of injury, mental health, alcohol abuse depressive disorders,

and demographics such as age, sex, race, and socioeconomic background were all

evaluated. The results showed that there is a twofold increase in suicide from all

age group, and self-inflicted injury has increased over the past 20 years in all

demographic sample groups. The result is consistent with many other studies

25

showing the increasing rate of suicide (Brickman & Mintz, 2003; Larkin, Smith &

Beautrais, 2008; Jayaram, 2014).

Screening in the ED can be an important intervention in reducing the

suicide risk across the different life span. Horowitz et al. (2001) studied the urban

pediatric population using the 14-item screening tool Risk of Suicide

Questionnaire (RSQ). The researchers showed that four questions: 1.) past, and

2.) present thoughts of suicide, 3.) prior self-destructive behavior, and 4.) current

stressors) identified 98% of the at-risk adolescents. However, the study was

limited to pediatric population so the results cannot be generalized to all

population. The 4-item RSQ demonstrated high content validity and includes most

of the risk factors identified in other studies (Horowitz et al., 2001).

In order to test the generalizability of the 4-item RSQ, Folse & Hahn

(2009) conducted another study using the same 4-item RSQ. This qualitative study

evaluated the reliability and validity of a 4-item version of the RSQ in the ED in

the adolescent, adult and geriatric patient irrespective of the chief presenting

symptom or psychiatric history. The 4-item RSQ include:1). Are you here because

you tried to hurt yourself? 2.) In the past week, have you been having thoughts

about killing yourself? 3.) Have you ever tried to hurt yourself in the past? 4.) Has

something very stressful happened recently that is hard to handle? These questions

proved to be reliable in the pediatric population, but literature review shows that

these questions should also be included in triage assessments. All of these four

26

questions are included in the SAFE-T teaching.

In order to test a brief screening tool with a larger population, Allen et al.

(2013) conducted a quantitative longitudinal study that tested a brief screening

tool. A convenience sample from 6 ED sites, over 6 months were used.

Demographic data included sex, race, age, and gender. Participants were asked 5-

item questionnaire that included inquiry regarding hopelessness, depression,

wanting to die, any suicidal thoughts, and prior history of suicide. The authors

looked at the different factors for suicide screening such as instrument, age,

training, frequency of screening, and treatment of suicidal patients in the ED

(Allen et al., 2013), all of which are also incorporated into the SAFE-T teaching.

Results and Gaps in Research

Robst (2015) stated that there should be more emphasis on suicide

assessment for patients presenting with medical diagnosis, and poisoning-related

diagnosis. The JC safety standards should also be standardized, so that the

implementation is the same for all providers. Limitations include inaccurate data

related to coding, and inconsistency in the implementation of JC guideline. The

focus was limited to Medicaid patients, so results cannot be generalized to all

insurance (Robst, 2015).

In addition to assessment of medical diagnosis, Betz et al. (2013) showed

that emphasis should not only be identification of suicidal patients. It should also

27

include services such as referral, counseling services or access to mental health

care providers. Future implications showed there are multiple needs regarding

education and skills training for identification of suicidal patients in the ED.

Referral to other services such as counseling and access to mental health also

needs to be addressed. Limitations include poor administrative support,

inconsistency in training, limited generalizability of the results, and no verification

of the self-reported answers on the survey (Betz et al., 2013).

To understand long term development of suicide in the population, Ting et

al. (2012) showed the importance of knowing the epidemiological trends of

suicide in the ED, as well as knowing what suicide-risk assessment tool is

appropriate for the patient population. Limitations include inaccurate data, limited

generalizability of the result, low screening rates and poor documentation (Ting et

al., 2012).

Two studies focused on suicide assessment tools including Folse & Hahn

(2009), and Allen et al. (2013). Folse & Hahn (2009) proved that the 4-item RSQ

tool has a low level of reliability for all participants. The strengths include the

tool’s ease of use, and the ability to assess patient’s emotional, psychological and

mental health issues. The researchers showed that nurses need more education

regarding assessment of mental health related issues in the ED triage. Limitations

include the age and the size of the participants because it included adults and

geriatric, but the RSQ was originally designed and trialed for the pediatric age.

28

The RSQ questions are sensitive and very personal in nature, so it is very unlikely

that the participants would answer the questions in a consistent manner. The

sample size included varied age representation, but only included African

Americans and Caucasians, and this limits the generalizability of the results. The

number of nurses participating was very limited, as well as the variation and

unreliable documentation in the data. The 4-item questions should be asked for all

patients in the ED, and should be included as part of the triage assessment (Folse

& Hahn, 2009).

Allen et al. (2013) showed that prior history of suicide is the strongest

predictor for suicide, passive suicide ideation was present at 79%, and depression

was very common for all participants. Future implications show that all patients

should be assessed for prior history of suicide, as this is the strongest predictor of

suicide attempts. Depression also shows strong correlation, therefore must be

addressed for all patients. Limitations include small sample size and small racial

representation, limited generalizability and the instrument is not used widely and

has not been validated yet. Allen et al. (2013) identified the same risk factors that

are included in the SAFE-T teaching.

Summary

In summary, the literature review included information about suicide,

epidemiological statistics, suicide risk factors, and the need for further studies to

29

test the reliability and validity of a suicide assessment tool. Although the risk

factors for suicide are well documented (Perry et al., 2012), there is very limited

information regarding the use of standardized suicide assessment tool because the

risk factors are too many to list (Tran et al., 2014). In spite the attempts to put

together these risk factors into score and create an algorithm to predict suicide

(Hetta, Marlow, Sjostrom, & Waern, 2010; Jokinen, Nordstrom & Steffanson

2012), the results are poor and unreliable (Bolton, Sareen, & Spiwak, 2012; Ryan

& Large, 2013). There are also very few of suicide prevention interventions

(Chesin & Stanley, 2013). Researchers showed that ED presents many

impediments such as inadequate research funding, limited experienced

researchers, and the turbulent environment strained with patient overcrowding and

restricted resources, which makes it a difficult place to conduct research

(D’Onofrio et al., 2010).

The most common recommendation from all studies includes the need for

physician and nursing education and development regarding risk assessment and

interventions for suicidal patients (Chesin & Stanley, 2013; Coombs & Romm, 2007;

Jayaram, 2014; JC, 2013; Patterson & Hughes, 2008; Reid, 2010). Researchers show

overwhelming evidence that supports the education and training of clinical staff

regarding suicide assessment and identification of risk factors. All of these

recommendations are all included in the SAFE-T teaching to be conducted for the ED

nurses.

30

CHAPTER 3: METHODOLOGY

Research Design and Method

According to the APAPGATPSB (2006), even though there are a number of

suicide assessment tools available, they can only assist the clinician in predicting

suicidality, and no such rating scale can substitute for a comprehensive and careful

clinical evaluation of patients. Teaching will be conducted to all 30 ED nurses at a VA

ED using SAFE-T. Permission for SAFE-T use was granted from the author Dr. Douglas

Jacobs, M.D.

The SAFE-T tool was chosen because it is the only tool that was designed

specifically for the ED triage area. The assessment must be concise and accurate because

the triage area is the first entry to ED. The ED nurse must provide an efficient and quality

care so that the next patient waiting to be seen can be given medical attention right away.

Scrofine & Fitzsimons (2014) showed that longer wait times are associated to poor health

outcomes, increased potential for adverse effects, and can contribute to increase length of

stay.

The SAFE-T also incorporates evidence-based suicide assessment for the ED

triage, and includes specific risk factors inherent in the veteran population such as access

to weapons, mental health issues, traumatic brain injury, substance abuse and many other

risk factors (Neyback, 2008). It also includes interventions and nursing plan of care for

low, moderate and high-risk suicidal patients commonly seen at this VA ED, and more

importantly, SAFE-T satisfies most of the elements required by JC (2015).

31

This project involved a two-step quantitative descriptive post-intervention

design study. The first step was to teach the nurses about SAFE-T tool (see

Appendix A), which included: 1.) identification of suicide risk factors, 2.)

identification of protective factors, 3.) conducting a suicide inquiry,

4.) determination of risk level and the appropriate intervention, 5.) documentation.

The second step involved completing the Post Testing Evaluation Tool

(PTET), which evaluated the knowledge learned by the nurses regarding SAFE-T

tool. The participants included a convenience sample of 30 VA ED nurses. The

teaching will took 3 hours to complete per staff, and was conducted over 3 weeks.

The teaching was conducted by the primary investigator, and the PowerPoint

teaching handout were included (see Appendix C), as well as the SAFE-T tool (see

Appendix A). The location will be at the ED Conference Room at a VA Medical

Center. The PTET (see Appendix B) was given to the nurses after the teaching is

completed. It took approximately 5-10 minutes to complete the evaluation form.

Potential Benefits

The potential benefits of providing nurses with teaching regarding

assessment, care and management of suicidal patient include satisfying the JC

National Patient Safety Goal #15, which mandates that the organization identify

safety risks present in its patient population. This include the: 1.) Assessment of

variables that may increase or decrease risk of suicide, 2.) Meeting the patient’s

safety needs, and setting for treatments are addressed, 3.) The organization

32

provides information to individuals and their family members for crisis situations

(NPSG, 2015). In addition, it will increase safety in the ED because it will provide

consistency, guidance and structure for the nurses managing this high-risk patient

population.

Subjects

Consent

The IRB was approved at the VA ED facility, as well as at Fresno State

School of Nursing in 2015. Voluntary consent form was provided prior to the

teaching session. The consent form included the problem identified, goal,

timeline, date, location, and details of the study. It also stated that participation is

voluntary, and they can choose to decline without any penalty or loss of benefit

(see Appendix D).

Subject Characteristics. The participants included a convenience sample of 30

VA ED nurses. The nurses consisted of both male and female, ranging from 29 to

65 years old. Years of nursing experience ranged from 1-35 years of ED nursing.

Education varied from Associate Degree in Nursing, Bachelors and Masters

prepared nursing degrees, and all of the nurses are English proficient. There was

no use of special groups or subjects whose capacity to provide informed consent

may be absent or limited.

33

Setting

Teaching was conducted in the ED Conference Room from February 1-29,

and took 3 hours per educational session with staff. The staff was provided a clean

and quiet environment that is conducive for learning.

Potential Risks and Management

Identification of Risks. The subject’s participation was voluntary, and they

were informed that they can withdraw anytime. There were very minimal

psychological, social, physical, economic and legal risks associated with

participation in this quality improvement project.

Psychological and Social Risks. There was very minimal social or

psychological risk for the participants. The participants were informed that in the

event that personal issues or problems arise, they can be referred to Employee

Assistance Program (EAP).The EAP is a toll-free number that provides 24/7

support with counselors, crisis management, educational information, and this is a

free and confidential service for employees.

Physical Risks. There was no anticipated physical risk identified related to

this project. The subjects were provided a safe area where the education took

place. There was no physical pain, discomfort or injury that resulted from

participating in the SAFE-T teaching.

Economic Risks. There was very minimal economic risk related to the

staffing for the ED. The teaching time took three hours, and it was scheduled

34

during non-peak hours in the ED. The teaching was done during regular working

hours, so there was no additional cost for the unit.

Legal Risks. There was minimal risk related to confidentiality and failure

to protect the subject’s identity. In order to protect the participant’s privacy, the

post-teaching evaluation tool was kept confidential. The evaluation forms did not

include the name of any nursing staff involved in the project, and was kept in a

locked file. The primary investigator was the only person who had access to the

PTET.

Data Monitoring. Evaluation forms were kept in a locked environment,

and the forms were destroyed after the study was completed. The evaluation forms

did not include any participant identifier, and all the responses were kept

anonymous to protect the participant’s privacy.

Costs

The subjects of this study did not incur any costs as a result of their

participation, and the Emergency Department did not incur additional cost as well.

The 3 hours teaching time counted towards continuing education, and this was

covered within the participant’s educational benefits.

Compensation and Incentives

There was no compensation or incentive offered for anyone involved in this

research project. The participation of all subjects was voluntary, and there was no

compensation of any kind involved.

35

Post-Teaching Evaluation Tool

At the end of the teaching session, each participant was given a PTET (see

Appendix B) to fill out. The PTET included demographic data such as age,

ethnicity, level of education, marital status, employment status, total nursing years

of experience and total years worked in the ED. It also included eleven questions

that evaluated whether the content of the teaching improved the identification of

risk and protective factors that can be developed, and increased overall knowledge

regarding managing suicidal patients in the ED (see Appendix B).

Analyzing Data

The results of the PTET were analyzed using descriptive statistics using Statistical

Package for the Social Science (SPSS). The responses included categorical or nominal

data such as age, categorical data such as gender, ordinal data such as years of nursing

experience, education, and knowledge in care of suicidal patients. The discussion of the

sample demographics, reliability analysis, descriptive statistics, data screening, research

question, and conclusions were included.

Gaps in Literature

The setting of this project was different from other research because the SAFE-T

tool was recommended for use in triage for the general population, but literature has not

shown it implemented in the veteran population where majority of the patient population

have mental health issues. Educating the nurses about SAFE-T supported the goal of this

DNP project because it included the identification and assessment of many risk factors

36

associated with suicide in the veteran ED population.

Study Step Sequence

1. Consent was acquired for all ED nurse participants. The consent included

information such as the problem identified, and the goal of the quality

improvement project in the ED.

2. Teaching was conducted in the ED Conference Room from Feb 1-29, and

the teaching took 3 hours to complete per staff.

3. PTET was given to all participants after the teaching was completed, and it

took approximately 10-15 minutes to complete.

4. Data collected were analyzed using SPSS.

CHAPTER 4: RESULTS

Introduction

The purpose of this study was to determine whether a teaching intervention

improved the knowledge of nurses in the assessment, care and management of

suicidal patients admitted to the emergency ED. A benefit of providing nurses

with teaching regarding assessment, care and management of suicidal patients

include satisfying the JC NPSG #15, which mandates that the organization identify

safety risks present in its patient population (JC, 2013). More importantly,

educating the nurses will increase safety in the ED because it will provide

37

consistency, guidance and structure for the nurses managing this high-risk patient

population.

The teaching intervention was conducted with 30 ED nurses using Suicide

SAFE-T. Permission for SAFE-T use was granted from the author Dr. Douglas

Jacobs, MD. Each educational session lasted for 3 hours per staff, and was

conducted from February 1-29. After the teaching intervention, the ED nurses

were given a Post-Teaching Evaluation Tool (PTET) to determine to what extent

their knowledge improved as a result of the intervention. Statistical analysis was

conducted using the Statistical Package for Social Scientists (SSPS 8.0 for

Microsoft Windows). Research hypotheses were tested at the alpha level of .05.

Chapter four is organized by a discussion of the sample demographics,

reliability analysis, descriptive statistics and data screening, research question, and

conclusions. The following provides a discussion of the sample demographics

Sample Demographics

The sample consisted of 30 nurses; 56.7% (n = 17) were 25 to 44 years of

age; and the remaining 43.3% (n = 13) were 45 to 74 years of age. Age group is

presented (see Table 1).

Table 1

Age Group of Registered Nurses

Age Group n % Cumulative %

25-34 7 23.3 23.3

35-44 10 33.3 56.7

38

45-54 7 23.3 80.0

55-64 5 16.7 96.7

65-74 1 3.3 100.0

Total 30 100.0

Ethnicity, 56.7% (n = 17) were white or Caucasian; 40% (n = 12) were

Asians or Pacific Islanders; and 3.3% (n = 1) were Native Americans or American

Indians. Regarding highest level of nursing education, 13.3% (n = 4) had

associate’s degrees; 83.3% (n = 25) had bachelor’s degrees; and 3.3% (n = 1) had

master’s degrees. Regarding marital status, 76.7% (n = 23) were married or in

domestic partnerships; whereas 23.3% (n = 7) were single, never married. All

(100%, n = 30) nurses were employed on a full-time status.

Participants had varying years of nursing experience. For example, one-

third (33.3%, n = 10) of nurses had less than 10 years of experience; 30% (n = 9)

had 15-19 years; and 30% (n = 9) had more than 20 years of experience. Years of

nursing experience are presented (see Table 2).

39

Table 2

Years of Nursing Experience

Experience n % Cumulative %

1-4 years 5 16.7 16.7

5-9 years 5 16.7 33.3

10-14 years 2 6.7 40.0

15-19 years 9 30.0 70.0

20-24 years 4 13.3 83.3

25-29 years 2 6.7 90.0

35 years or more 3 10.0 100.0

Total 30 100.0

Regarding emergency department experience, 36.7% (n = 11) had 1 to 9 years

of experience; a third (33.3%, n = 10) had 15-19 years of experience; and 23.3%

(n = 7) had 20 or more years of experience. Emergency department experience is

presented (see Table 3).

Table 3

Emergency Department Years of Experience

Experience n % Cumulative %

1-4 years 5 16.7 16.7

5-9 years 6 20.0 36.7

10-14 years 2 6.7 43.3

15-19 years 10 33.3 76.7

20-24 years 4 13.3 90.0

35 years or more 3 10.0 100.0

Total 30 100.0

40

Reliability Analysis

The reliability of the PTET was tested with Cronbach’s alpha. For

knowledge improvement, α = .62. The minimum acceptable reliability is .70. An

inter-item analysis was conducted. Based on the analysis, the reliability could not

be improved substantially by removing any of the items. The item total statistics

are presented (see Table 4).

Table 4

Inter-Item Analysis

Item

Scale

Mean if

Item

Deleted

Scale

Variance if

Item

Deleted

Corrected

Item-Total

Correlation

Cronbach's

Alpha if

Item Deleted

1. Did the care plan teaching

increase knowledge in

identifying the different risk

factors associated with

suicide?

45.10 6.60 .444 .552



identifying two protective

factors that may, or may not

offset acute risk?

45.03 7.39 .224 .605



identifying the three

different suicide risk levels

and their clinical

presentation?

44.97 6.89 .439 .559

41



identifying specific

questions related to suicidal

thoughts, plans, behavior

and intent?

44.76 8.19 .041 .634


increase knowledge

regarding possible

interventions for high-risk

suicidal patients?

44.79 7.60 .201 .608


increase knowledge

regarding possible

interventions for moderate

risk suicidal patients?

45.07 7.42 .220 .606


increase knowledge

regarding possible

interventions for low-risk

suicidal patients?

45.07 6.28 .432 .552


increase knowledge

regarding what information

should be included in the

patient teaching?

44.93 7.07 .317 .584



identifying critical times

when additional

documentation is needed for

suicide risk assessment?

44.86 7.55 .262 .597

10. Did the care plan

teaching increase knowledge

regarding information that

should be included in the

nursing documentation?

44.93 7.85 .150 .617

42

11. Overall, did the teaching

increase knowledge

regarding assessment and

care of suicidal patients in

the ED?

44.62 7.74 .272 .597

Descriptive Statistics and Data Screening

Knowledge improvement was computed by calculating the mean responses.

Values could range from 1(disagree) to 5 (strongly agree) with higher values

indicating higher agreement that the teaching intervention resulted in knowledge

improvement. For the sample of nurses, scores ranged from 4 to 5 (M = 4.50, SD =

0.26). Data were screened for normality with skewness and kurtosis statistics. In

SPSS, distributions are considered to be normal if their absolute values are less

than two times their standard errors. The skewness = 0 (SE = .43) and the kurtosis

= -0.28 (SE = 0.83). Therefore, the distribution of scores was within normal limits

(see Figure 1).

43

Figure 1: Histogram for Knowledge Improvement

Research Question

One research question was formulated for investigation. It was as follows:

Would the teaching and introduction of an evidence based triage tool increase the

nurses’ knowledge regarding assessment and management of suicidal patients in

the Emergency Department? The research question was answered with descriptive

statistics. Frequency distributions were generated for each item on the PTET and

their associated responses. As indicated in Table 5, no nurses disagreed that the

teaching intervention increased knowledge. Five or less were neutral in their

44

feedback depending on the question, but the majority of nurses agreed or strongly

agreed that the training module improved knowledge.

Table 5

Summary of Responses

Question

Disagree

Strongly

Disagree

Neither

Agree or

Disagree Agree

Strongly

Agree

Count Count Count Count Count




factors associated with

suicide?

0 0 3 14 13



identifying two protective

factors that may, or may not

offset acute risk?

0 0 2 14 14



identifying the three different

suicide risk levels and their

clinical presentation?

0 0 1 14 15



identifying specific questions

related to suicidal thoughts,

plans, behavior and intent?

0 0 0 11 19


increase knowledge regarding

possible interventions for

high-risk suicidal patients?

0 0 1 9 20

45




moderate risk suicidal

patients?

0 0 2 16 12



possible interventions for low-


0 0 5 10 15



what information should be

included in the patient

teaching?

0 0 2 12 16



identifying critical times when

additional documentation is

needed for suicide risk

assessment?

0 0 0 13 16



information that should be

included in the nursing

documentation?

0 0 0 15 15



assessment and care of

suicidal patients in the ED?

0 0 0 6 24

As previously mentioned, knowledge improvement was also computed by

calculating the mean responses. Values could range from 1(disagree) to 5 (strongly

agree) with higher values indicating higher agreement that the teaching

intervention resulted in knowledge improvement. For the sample of nurses, scores

ranged from 4 to 5 (M = 4.50, SD = 0.26). Four represented “agree” and 5

46

represented “strongly agree.” Therefore, nurses agreed and strongly agreed that the

training module improved knowledge.

Ancillary Analyses

Ancillary analyses were conducted in order to determine what, if any

additional factors were associated with knowledge improvement besides the

training module. Specifically, years of nursing experience, years of emergency

department experience, and nurses’ ages were examined. The Pearson Product

Moment correlation (Pearson r) was used to investigate the bivariate relationships.

A correlation matrix is presented (see Table 6).

Table 6

Correlation Matrix

Variable Knowledge

Improvement

Years of

Nursing

Experience

Emergency

Department

Experience

Age

Knowledge

Improvement __ .572** .449* .446*

Years of Nursing

Experience __ .841** .819***

Emergency

Department

Experience

__ .659***

Age __

Note. ***p < .001, **p < .01, *p < .05; N = 30. Although some variables were on

an ordinal scale of measurement, the Spearman’s who would have yielded similar

results.

Years of nursing experience was significantly and positively related to

knowledge improvement, r(28) = .57, p = .001, two-tailed. As years of nursing

47

experience increased, there was a corresponding increase in knowledge

improvement. Emergency department experience was significantly and positively

related to knowledge improvement, r(28) = .45, p = .013, two-tailed. As

emergency department experience increased, there was a corresponding increase

in knowledge improvement. Age was significantly and positively related to

knowledge improvement, r(28) = .45, p = .013, two-tailed. As age increased, there

was a corresponding increase in knowledge improvement. A scatterplot matrix is

presented (see Figure 2).

Figure 2. Scatterplot Matrix of Knowledge Improvement and Related Variables

Conclusions

The research question was formulated for investigation. It was determined

that nurses “agreed” and “strongly agreed” that the training module improved

knowledge. Additional analyses were conducted. Specifically, years of nursing

experience, years of emergency department experience, and nurses’ ages were

48

examined in order to determine if they were also associated with knowledge

improvement. Years of nursing experience was significantly and positively related

to knowledge improvement. Emergency department experience was significantly

and positively related to knowledge improvement. Age was significantly and

positively related to knowledge improvement.

CHAPTER 5: CONCLUSION

Discussion

Suicide remains to be one of the top 10 reasons for death in the country,

and in 2013, there are approximately 113 suicides daily, or one every 13 minutes

(CDC, 2013). The ED visit provides an opportunity to initiate the suicide

assessment and screening when the patient presents there for medical care. The

ED triage is where the first nurse-patient interaction happens, therefore the triage

nurse plays a critical role in the assessment of all patients seen in the ED. It is

imperative that the triage nurse is educated regarding suicidal assessment,

identifying risk factors, knowing the risk levels and appropriate interventions,

exploring thought process, and implementing care of those with positive suicide

screens in the ED (Jacobs, 2007). It is imperative that the nurses are provided

proper education and training because inconsistency in suicide assessment can

lead to delay in care, possible adverse events such as a suicidal attempt in a

hospital, which is considered a “never event.” (Centers for Medicare and Medicaid

Services, 2006).

49

This quality improvement DNP project provided education to registered

nurses regarding assessment, care and management of suicidal patients using

SAFE-T triage tool. It was hypothesized that the implementation of SAFE-T

teaching would increase their overall knowledge in assessing and managing

suicidal patients in the ED, and this was supported by the results of the

investigation. The results showed that nurses that the training module improved

knowledge. There were also strong correlations when additional analyses were

conducted. These include years of nursing experience, years of emergency

department experience, and nurses’ ages were examined in order to determine if

they were also associated with knowledge improvement. Years of nursing

experience was significantly and positively related to knowledge improvement.

Emergency department experience was significantly and positively related to

knowledge improvement. Age was significantly and positively related to

knowledge improvement.

Limitations

Limitations for this study included the lack of pre-test and small sample

size (n=30 nurses). The sample size was limited to convenience sample of full-

time emergency department nurses at the VA ED that were mostly females, and

were not ethnically diverse. The VA ED where the project was conducted may not

have the same patient population compared to other EDs, and this can minimize

the generalizability of the results.

50

Implications for Nursing Practice

This DNP quality improvement project originated as a result of an observed

need to provide teaching and education to ED nurses in order to improve the triage

and assessment of suicidal patients, and more importantly, to comply with NPSG

#15. Researchers showed that there is a need for nursing education and training

regarding suicide assessment, the use of improved screening, and implementation

of safety measures (Harowitz et al., 2013; Jayaram, 2014; Patterson & Hughes,

2008; Reid, 2010) also identified the absence of appropriate patient assessment

was the primary reason for 80% of hospital-related suicides.

This project is unique because this VA sees a lot of suicidal patients, but

lacks a formal and standardized suicide assessment, education and training for the

nurses in the ED. Teaching the SAFE-T triage tool is the first evidence-based

triage suicide tool that has been introduced to the this VA ED nurses, and this is an

important contribution to improve safety and quality of the nursing practice. The

overall cost to educate the nurses is very minimal, and it took a very short time to

achieve this goal. Suggestions for future research include continued training for all

of the nursing staff in the ED, including part-time and intermittent per diems.

Obtaining a pre-test would also help with accurate data collection and analysis. It

would also be helpful to include barriers to learning that are identified by

participants.

51

Conclusion

In conclusion, this quality improvement DNP project supports evidence-

based research regarding nursing education for assessment, care and management

of suicidal patients in the ED. The U.S. Preventive Services Task Force (USPSTF)

(2004) reported that there is more research to be done regarding universal

screening for suicide, and that there is limited evidence on the accuracy of

screening tools to help identify suicidal risk. However, many organizations are

implementing policies to comply with NPSG #15 (USPSTF, 2004). The

introduction of the SAFE-T triage tool satisfies the NPSG #15 by providing a

structure and formal education addressing the suicidal-risk population.

The results showed that SAFE-T triage tool reflected the nurses’ response

that they “agreed” and “strongly agreed” that the training module improved

overall knowledge. It is the goal, that by educating the nurses regarding SAFE-T

triage tool, the patients presenting to ED with suicidal ideation can be accurately

identified, a safety plan can be implemented and the treatment plans can be started

as soon as possible without any delays. The SAFE-T triage tool supports the

strong need to increase nursing level of awareness, knowledge and competence in

taking care of suicidal patients.

52

REFERENCES

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among emergency department medical patients: instrument and results from

the psychiatric emergency research collaboration. Suicide & Life-

Threatening Behavior, 43(3), 313-323.

American Psychiatric Association Practice Guideline for the Assessment and

Treatment of Patients with Suicidal Behaviors (2006). Practice guideline

for assessment and treatment of patients with suicidal behaviors. Retrieved

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APPENDIX A: SUICIDE ASSESSMENT FIVE-STEP EVALUATION AND TRIAGE (SAFE-T)

63

APPENDIX A: SUICIDE ASSESSMENT FIVE-STEP EVALUATION AND TRIAGE (SAFE-T)

64

APPENDIX B: POST-TEACHING EVALUATION FORM

68

APPENDDIX B: POST TEACHING EVALUATION FROM

Evaluation of Knowledge Improvement Post-Teaching Implementation of Suicide Assessment

Five-Step Evaluation and Triage

(SAFE-T) Teaching in the Emergency Department:

DEMOGRAPHIC DATA:

What is your age?

o 22-24 years old

o 25-34 years old

o 35-44 years old

o 45-54 years old

o 55-64 years old

o 65-74 years old

o 75 years or older

What is your ethnicity?

o White or Caucasian

o Hispanic or Latino

o Black or African American

o Native American or American Indian

o Asian or Pacific Islander

o Other- please specify

What is your highest level of education?

o Associate’s Degree

o Bachelor’s Degree

o Master’s Degree

o Doctoral Degree

What is your marital status?

o Single, never married

o Married or domestic partnership

o Widowed

o Divorced

o Separated

What is your employment status?

o Full time

o Part-time

o Intermittent/Per diem

How many years of nursing experience do you have?

o 1-4 years

o 5-9 years

o 15-19 years

66

o 20-24 years

o 25-29 years

o 30-34 years

o 35 years or more

How many years have you worked in the Emergency Department?

o 1-4 years

o 5-9 years

o 15-19 years

o 20-24 years

o 25-29 years

o 30-34 years

o 35 years or more

Evaluation of Knowledge Improvement Post-Teaching Implementation

of Suicide Assessment Five-Step Evaluation and Triage

(SAFE-T) Teaching in the Emergency Department:

Rating Scale Disagree

1

Strongly

Disagree

2

Neither

Agree or

Disagree

Agree

4

Strongly

Agree

5




factors associated with suicide?



identifying two protective factors

that may, or may not offset acute

risk?



identifying the three different

suicide risk levels and their

clinical presentation?



identifying specific questions

related to suicidal thoughts,

plans, behavior and intent?



possible interventions for high-




67


moderate risk suicidal patients?



possible interventions for low-




what information should be

included in the patient teaching?



identifying critical times when

additional documentation is

needed for suicide risk

assessment?



information that should be

included in the nursing

documentation?



assessment and care of suicidal

patients in the ED?

68

APPENDIX C: EDUCATION MATERIALS

69

APPENDIX C: EDUCATION MATERIALS

Slide 1

Good morning everyone, and thank you for agreeing to participate in this

project. My name is Evangeline Rico, and I am a pursuing a doctorate in nursing

practice at the California State University Fresno. The goal of this quality

improvement project is to educate the nurses about a Nursing Care Plan regarding

the Assessment and Management of Suicidal patients in the Emergency

Department. The teaching will include information from Suicide Assessment Five-

Step Evaluation and Triage (SAFE-T), which is developed as a collaboration

between Dr. Douglas Jacobs, Screening for Mental Health Inc., Suicide Prevention

Resource Center and Substance Abuse and Mental Health Services Administration.

Once the teaching is completed, a questionnaire will be passed out to

evaluate if the teaching increased the understanding of nurses regarding suicide

assessment and management.

The evaluation would include:

1.) identification of the different risk factors associated with suicide

2.) identification of internal and external protective factors that may, or may not

offset acute risk.

3.) inquiry or questions related to suicidal thoughts, plans, behavior and intent.

Teaching Plan for Registered Nurses:

Emergency Department: Suicide

Assessment Five-Step Evaluation and

Triage (SAFE-T)

Evangeline Rico, RN, MSN, WCC, CNL

70

4.) nursing assessments for risk level, and discussion of possible interventions for

low, moderate and high risk suicidal patients.

Slide 2

Slide 3

Background: According to the Center for Disease Control and Prevention

(2007) suicide was the 11th leading cause of death for all

ages, and that there are approximately 100 to 200 attempts

for every completed suicide (CDC, 2007). The Joint

Commission (JC) Sentinel Event Alert (2010) reported that

suicide is one of the most reported sentinel event, and 8% of

suicide attempts occur in the Emergency Department (JC,

2010). As a result, the JC created National Patient Safety

Goal (NPSG) 15.01.01 in 2010, that states all patients will

be assessed to identify risk for suicidal ideation (SI) (JC,

2010).

Background: cont. The Department of Veterans Affairs examined suicide in the

military veterans, and it showed that an average of 18 veterans committed suicide on a daily basis (Huggins, 2011). Veterans presenting with higher suicide rate is associated with availability and knowledge in use of firearms, psychiatric conditions such as depression, post-traumatic stress disorder (PTSD) (Desai, Dausey, & Rosenbeck, 2008), and traumatic brain injury (Warden, 2006). Among all of these, PTSD is the most common mental disorder resulting from military combat, and is caused by trauma, life threatening events, natural disaster, terrorist attack, accidents or personal assaults such as rape (Huggins, 2011).

71

Slide 4

Slide 5

Problem: The San Francisco Veterans Affairs Medical Center Emergency

Department (SFVAMC ED) triages approximately seventy to one hundred patients per day. These include mental health patients with depression, mood disorder, substance abuse, psychiatric problems, PTSD, or other mental health issues that presents with suicidal ideation (SI). Currently, per Joint Commission requirement, hospital policy, all patients seen in the ED are triaged by the nurse, and are assessed for SI. However, it is problematic because there is no standardized evidence-based triage tool used to in triage to assess patients, resulting in high risk suicidal patients not being correctly identified.

In addition, once the patient is identified as suicidal, there is no standardized clinical pathway or plan of care for these high-risk patients.

Outcomes The participants will be able to identify the different risk

factors associated with suicide.

The participants will be able to identify internal and

external protective factors that may, or may not offset

acute risk.

The participant will inquire about questions related to

suicidal thoughts, plans, behavior and intent.

The participant will assess for risk level, and discuss

possible interventions.

72

Slide 6

Slide 7

Suicide Assessment

Five-Step Evaluation

and Triage

Step 1: Identification of Risk Factors

Step 2: Identification of Protective Factors

Step 3: Conduct Suicide Inquiry

Step 4: Determine Risk Level/Interventions

Step 5: Documentation

73

Slide 8

Slide 9

All patients seen at the San Francisco Veterans Affairs

Medical Center must be assessed by the triage nurse

for suicidal ideation.

Suicide assessment should be done at the first contact

with the patient.

I. RISK FACTORS SUICIDE BEHAVIOR: history of prior suicide, aborted

suicide attempts, or hisotry of any self-injury

CURRENT/PAST PSYCHIATRIC DISORDERS:

especially mood disorders, psychotic disorders,

alcohol/substance abuse, ADHD, TBI, PTSD, conduct

disorders (antisocial, aggression, impulsivity)

74

Slide 10

Precipitants/Stressors/Interpersonal: Financial or health status, real or anticipated,

triggering events, humiliation shame or despair, ongoing medical issues (i.e. CNS

disorders, pain). Intoxication, family

Slide 11

I. RISK FACTORS continued KEY SYMPTOMS: anhedonia (inability to feel

pleasure), impulsivity, hopelessness, anxiety, panic,

insomnia, hallucinations

FAMILY HISTORY: of suicide attempts, psychiatric

disorders requiring hospitalizations

PRECIPITANTS/STRESSORS/INTERPERSONAL

I. RISK FACTORS cont

CHANGE IN TREATMENT: discharge from a

psychiatric hospital, provider or treatment change

ACCESS TO FIREARMS

75

Slide 12

Slide 13

III. SUICIDE INQUIRY- specific questioning about thoughts, plans, behaviors and

intent

Ideation: frequency, intensity, duration

Plan: Behaviors: rehearsals (loading a gun, tying noose),

Intent: explore reasons to die versus reasons to live

II. PROTECTIVE FACTORS

INTERNAL :ability to cope with stress, religious beliefs,

frustration tolerance

EXTERNAL: responsibility to children or pets, positive

therapeutic relationships, social support

III. SUICIDE INQUIRY

IDEATIO: frequency, intensity, duration

PLAN: timing, location, lethality, access to weapon, preparation

BEHAVIORS: past/aborted attempts, rehearsals versus self-injuries, explore ambivalence

INTENT: 1.) extent to carry out the plan, 2.) lethal plan vs self-injury

76

Slide 14

Slide 15

IV. RISK LEVEL/INTERVENTION

ASSESSMENT OF RISK: risk level is based on clinical

judgment

High

Moderate

Low

REASSESS as patient or environmental circumstance

change

IV. RISK LEVEL/INTERVENTION cont.

RISK

LEVEL

PROTECTIVE FACTOR SUICIDALITY POSSIBLE

INTERVENTIONS

HIGH Psychiatric Diagnosis

severe symptoms

Acute precipitating event

Protective factors not

relevant

• Potentially lethal

suicide attempt

• Persistent ideation

• Strong intent

• Suicidal rehearsal

• Admission

generally indicated

• Suicide precaution

MODERATE Multiple risk factors

Few protective factors

• Suicidal ideation with

plan, but NO intent

or behavior

• Admission

depending on risk

factors.

• Develop crisis

plan.

• Give emergency

crisis number.

LOW Modifiable risk factors

Strong protective factors

• Thoughts of death,

NO plan intent or

behavior

• Outpatient referral

• Symptoms

reduction.

• Give emergency

crisis number.

77

Slide 16

Slide 17

Expected Outcome:• The use of of an evidence based suicidal screening tool will

increase the rate of identification of high risk suicidal patients triaged in the ED.

• Nursing interventions will be created based on the identified suicide risk level such as low, moderate or high-risk suicide. This will create a safer environment for the patient, as well as the staff, because interventions will be based on the patient’s risk level for suicidality.

• The implementation of the project will also be beneficial for the hospital because it satisfies and complies with the JC guideline, and the National Patient Safety Goal for suicidal patients.

References:

Desai, R.A., Dausev, D., & Rosenheck, R.A. (2008). Suicide among discharged psychiatric inpatients in the department of veterans affairs. Military Medicine,173, 721-728.

Huggins, J.A. (2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services. Suicide and Life-Threatening Behavior, 41(4), 416-423

Jacobs, D. (2007). Suicide assessment five-step evaluation and triage (SAFE-T) for mental health professionals. Retrieved from http://www.stopasuicide.org/docs/Safe_T_Card_Mental_Health_Professionals.pdf

The Joint Commission (2010). A follow-up report on preventing suicide: focus on medical-surgical units and the emergency department. Sentinel Event Alert 2010, 46,1– 4.Retrieved from http://www.jointcommission.org/assets/1/18/SEA_46.

Warden, D. (2006) Military TBI during the Iraq and Afghanistan ward. The Journal of Head Trauma Rehabilitation, 21,398-402.

78

APPENDIX D: VOLUNTARY CONSENT FORM

79

APPENDIX D: VOLUNTARY CONSENT FORM

PROJECT TITLE: Teaching and Evaluation of Suicide Assessment Five-Step

Evaluation and Triage (SAFE-T) in the Emergency Department

Dear Prospective Research Participant:

I am asking for your help and cooperation in participating in a Quality

Improvement study in the Emergency Department. This study would be very

beneficial to the institution and the nursing staff by providing education regarding

Suicide Assessment Five-Step Evaluation and Triage (SAFE-T). The SAFE-T

teaching will include identification of risk and protective factors, comprehensive

suicide inquiry, determination of risk level and appropriate nursing interventions.

The 3-hour teaching will provide vital information regarding accurately identify

high-risk suicidal patients, and creating nursing interventions designed to decrease

risk for those with positive suicidal screen. Teaching will start February 1-29,

2016 and will be located in the ED conference room.

Your decision to participate is completely voluntary. This QI project has no

known economic, physical, psychological or social risks to participants. You are

not required to participate, and declining will involve no penalty or loss of benefits

to which you are entitled. If you agree to participate, you may choose not to

answer any given questions, and you may discontinue participation at any time

without penalty or loss of benefits.

Any information obtained from your participation will remain confidential. There

will be an 11-item post-teaching evaluation form that will be filled out

anonymously at the end of the teaching session. The teaching will not cost you

anything, and there will be no compensation for participation.

If you have any questions or concerns, please contact investigator, Evangeline

Rico (650) 228-3178. Thank you for your consideration in helping this quality

improvement study.

80

Your signature below indicates that you have decided to participate, having read

the information provided above.

Date:____________________________________________

Signature_________________________________________

Signature of Witness (if any)_________________________

Signature of Investigator____________________________

Documents

Teaching and Evaluation of Suicidal Assessment, Five-Step